Notably, while Medicare has all of the consumer protections the public has come to expect from the ACA (guaranteed coverage, ban on preexisting condition exclusions, and so forth), it does not have an individual mandate per se. Part A is funded by a mandatory payroll tax, which essentially makes participation in it obligatory.

In 2022, the cost of this tax break would roughly equal the bill’s savings from cutting tax credits and subsidies that help low- and moderate-income families in 20 states and the District of Columbia combined afford quality coverage and care (see chart).

Pursuing that approach, Mr. Walker said, would obviate differences between the states that did and did not expand Medicaid while averting the intractable split between conservative and centrist members of Congress over how to structure a replacement.

The governors pressed the officials about spending cuts to states, and voiced acute skepticism about the argument — advanced by supporters of the health care bill — that states could make up for any fiscal changes by experimenting with new ways of administering Medicaid.